Medi-Cal Long Term Care Programs, Benefits & Eligibility Requirements

Summary
Medicaid is a joint federal and state program, so its rules, coverage plans and even its name all vary by state. In California, Medicaid is known as Medi-Cal. This article focuses on Medi-Cal Long Term Care, which is different from regular Medicaid. Medi-Cal will help pay for long term care for California residents in a nursing home, in their home and in other residential settings through one of three programs – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers and Aged Blind and Disabled (ABD) Medicaid.

 

California Medicaid (Medi-Cal) Long Term Care Programs

Nursing Home / Institutional Medicaid

Medi-Cal will cover the cost of long term care in a nursing home for eligible California residents through Nursing Home / Institutional Medicaid. This includes payment for room and board, as well as all necessary medical and non-medical goods and services. These can include skilled nursing care, physician’s visits, mental health counseling, prescription medication, medication management, social activities and assistance with Activities of Daily Living (eating, bathing, moving, dressing and using the bathroom).

Some of the things that Medi-Cal won’t cover in a nursing home are a private room, specialized food, comfort items not considered routine (tobacco, sweets and cosmetics, for example), personal reading items, plants, flowers, and any care services not considered medically necessary.

Any Medi-Cal beneficiary who receives Nursing Home Medicaid coverage must give most of their income to the state to help pay for the cost of the nursing home. They are only allowed to keep a “personal needs allowance” of $35 / month. Medi-Cal recipients with no income can apply for the Supplemental Security Income/State Supplemental Program (SSI/SSP) to receive a monthly “personal needs allowance” from the state.

Nursing Home Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits.

 

Home and Community Based Service (HCBS) Waivers

HCBS Waivers pay for goods and services that help Medi-Cal recipients remain living in their home, or somewhere else “in the community,” instead of living in a nursing home. These other residences “in the community” include senior housing, assisted living facilities, the home of a family member or friend and public housing. The goods and services provided by HCBS Waivers can be medical (doctor’s visits, skilled nursing care, durable medical equipment or prescription medication) or non-medical (like personal care assistance with Activities of Daily Living such as getting out of bed, dressing, eating, bathing and toileting).

Unlike Nursing Home Medicaid, HCBS Waivers are not an entitlement. This means that even if a person is eligible for an HCBS Waiver and applies for it, they are not guaranteed to receive the benefits. California, like most states, has participation limits on its Waiver programs. So, if a Waiver program has reached its maximum number of participants, a newly accepted applicant for that program will be put on a wait list until a spot in the program becomes available.

Medi-Cal offers the following Home and Community Based Service Waiver programs relevant to California residents who require long term care:
• Medi-Cal Assisted Living Waiver (ALW) – pays for services for assisted living residents
• Community Based Adult Services (CBAS) – pays for adult day care
• Multipurpose Senior Services Program (MSSP) Waiver – pays for services in the home
• Home and Community-Based Alternatives (HCBA) Waiver – helps relocate from nursing home to community

Medi-Cal Assisted Living Waiver (ALW)
The Medi-Cal Assisted Living Waiver (ALW) covers assisted living services for elderly (age 65 and over) and disabled California residents who need a Nursing Facility Level of Care (NFLOC) but live instead in an Adult Residential Facility, Residential Care Facility for the Elderly or Public Subsidized Housing. The ALW does not cover room and board at these facilities, only services. The ALW is available in 15 California counties – Alameda, Contra Costa, Fresno, Kern, Los Angeles, Orange, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Clara and Sonoma. This Waiver is meant to delay relocation to a nursing home, and it can also be used to assist Medi-Cal recipients who have been living in a nursing home for a minimum of 60 days transition out of that nursing home and into an assisted living facility in the community.

Medi-Cal ALW recipients will get an individualized service plan that determines which benefits/services they will receive through the Waiver and how often they will receive them. The benefits can include medication management, personal care, skilled nursing/doctor’s visits, transportation and more.

Community Based Adult Services (CBAS) Program
The Community Based Adult Services Program covers adult day care and adult day health care to qualified individuals. This Waiver program is available statewide. Its services begin with an individual assessment that will determine the needs of the Medi-Cal recipient, which services they will receive through the CBAS Program and how often they will they will receive them. The services include adult day care, skilled nursing, personal care, a meal, transportation and more.

Multipurpose Senior Services Program (MSSP) Waiver
The Multipurpose Senior Services Program Waiver provides services for eligible seniors (age 65 and over) living in California who reside in their home or the home of a friend or family member. MSSP services are not available in Adult Residential Facilities or Residential Care Facilities for the Elderly, or adult foster care homes. The MSSP Waiver is also intended to help current nursing home residents transition back to their home or the home of a friend or family member. This Waiver is available in 45 counties in California. To see if the MSSP Waiver is available in your geographic region, go to this California Department of Aging page.

As part of the Multipurpose Senior Services Program Waiver, recipients will get an individualized service plan that determines which benefits they will receive through the MSSP Waiver and how often they will receive them. Please note that these benefits are primarily non-medical in nature. They include care management, adult day care, personal care, respite care, transportation and more.

Home and Community-Based Alternatives (HCBA) Waiver
California’s Home and Community-Based Alternatives Waiver provides services similar to those found in the Multipurpose Senior Services Program described above. What makes the HCBA Waiver different is that it is primarily intended to help qualified individuals who are living in a nursing home on a temporary basis but wish to return home. Individuals who are enrolled in this Waiver program will be provided with an individual care plan that details which benefits and services will be provided and how often they will be provided.

 

Aged Blind and Disabled / Regular Medicaid

Medi-Cal’s Aged Blind and Disabled (ABD) Medicaid, also known as Regular Medicaid, covers California residents who are blind, disabled or aged (65 and older) and live in the community. Like Nursing Home Medicaid, ABD Medicaid is an entitlement, which means that anyone who meets the requirements is guaranteed by law to receive the benefits without any wait.

ABD Medicaid offers a variety of long term care benefits and services, but the beneficiary qualifies for these benefits and services one at a time. That’s different from Nursing Home Medicaid, which makes all of its services immediately available for anyone who qualifies. This can work for ABD Medicaid recipients because they are not required to need a Nursing Facility Level of Care (NFLOC) to qualify, unlike Nursing Home Medicaid and Home and Community Based Service Waiver recipients. However, ABD Medicaid recipients in California are required to need help with Activities of Daily Living (moving, dressing, bathing, eating, toileting) to be eligible for long term care benefits.

In-Home Supportive Services Program
California’s ABD Medicaid provides many of its long term care benefits through Medi-Cal’s In-Home Supportive Services Program. There are four smaller programs within the IHSS Program, and the first two serve the majority of people enrolled in the IHSS Program:
1) Community First Choice Option (CFCO) – for Medi-Cal beneficiaries who require a Nursing Facility Level of Care (NFLOC)
2)Personal Care Services Program – for aged, blind or disabled Medi-Cal beneficiaries who need personal care assistance but do not require a Nursing Facility Level of Care
3) IHSS Plus Option Program (IPO) – provides payment for spouses or adult children who are caregivers for a Medi-Cal beneficiaries
4) IHSS Residual Program (IHSS-R) – provides a way for people who need IHSS care services but are not eligible for Medi-Cal to become eligible

Through one of these four programs, Medi-Cal’s In-Home Supportive Services Program provides the following benefits:
• Personal care services (non-medical assistance with Activities of Daily Living such as moving, bathing, dressing, toileting and eating)
• Teaching / demonstration services (caregiver will teach beneficiary to do housework, prepare meals, bathe, dress, etc.)
• Homemaker services (housecleaning, laundry, shopping, errands, cooking)
• Paramedical services (wound care, catheter care, injection assistance, blood sugar checks)
• Protective supervision (supervision for mentally impaired people)
• Transportation assistance (to and from necessary medical appointments)

When a person enters the IHSS Program, they will be assessed to see what services they need and how often they might need those services to remain safe and healthy in their home. For program participants who do not have severe impairments, the maximum number of hours of IHSS Program care is approximately 195 per month, while people with severe impairments can receive up to approximately 283 hours of care per month.

IHSS Program services can only be received in the home of the Medi-Cal beneficiary or the home of a family member. The services are not available in Adult Residential Facilities, Residential Care Facilities for the Elderly, adult foster care homes, community care facilities or long-term care facilities. More information on the IHSS Program can be found on this California Department of Social Services page. For a list of county IHSS Program offices, go to this CDSS page.

Program of All-Inclusive Care for the Elderly (PACE)
California’s Program of All-Inclusive Care for the Elderly coordinates medical, social service and non-medical personal needs of Regular Medicaid beneficiaries into one comprehensive plan and delivery system. PACE is intended to help people who need a nursing home level of care but want to keep residing and receiving care in their home or somewhere else in the community. This program can be used by people who are “dual eligible” for Medicaid and Medicare and will help them coordinate the care from those two programs. Many PACE services will be provided at a PACE Center in the community, and the program will provide transportation to and from the PACE Center. This program is not available statewide. To see where it is available, go to this California Department of Health Care Services page.

 

Eligibility Criteria For Medi-Cal Long Term Care Programs

To be eligible for Medi-Cal a person has to meet certain financial requirements and functional (medical) requirements. The financial requirements vary by the applicant’s marital status, if their spouse is also applying for Medicaid and what program they are applying for – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled / Regular Medicaid

  The easiest way to find the most current Medi-Cal eligibility criteria for one’s specific situation is to use our Medicaid Eligibility Requirements Finder tool.

 

Medi-Cal Nursing Home Medicaid Eligibility Criteria

Financial Requirements
California residents have to meet an asset limit in order to be financially eligible for Medi-Cal’s Nursing Home Medicaid. For a single applicant in 2022, the asset limit is $130,000, which means they must have $130,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities.

For married applicants with both spouses applying, the 2022 asset limit for Nursing Home Medicaid through Medi-Cal is $195,000 combined between the two applicants/spouses. For a married applicant with just one spouse applying, the 2022 asset limit is $130,000 for the applicant spouse and $137,400 for the non-applicant spouse.

Most states and programs also have an income limit as part of their financial criteria for Medicaid, but California’s Medi-Cal has no income limit when it comes to Nursing Home Medicaid. However, California residents who qualify for Nursing Home Medicaid must give all of their monthly income to the state to help offset the cost of the nursing home except for a $35 / month personal needs allowance.

Medi-Cal applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Medi-Cal has a “look-back” period of 2.5 years. This means the state will look back into the previous 2.5 years of the applicant’s financial records to make sure they have not given away assets. California is in the process of removing the asset limit as part of Medi-Cal eligibility, but this has not happened yet, so Medi-Cal applicants should still be sure not to break the “look-back” rule.

Functional Requirements
The functional, or medical, criteria for Medi-Cal’s Nursing Home Medicaid is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

Medi-Cal Home and Community Based Services (HCBS) Waivers Eligibility Criteria

Financial Requirements
California residents have to meet an an asset limit and an income limit and in order to be financially eligible for Home and Community Based Service (HCBS) Waivers. For a single applicant in 2022, the asset limit is $130,000, which means they must have $130,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $1,564 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.

For married applicants with both spouses applying, the 2022 asset limit for HCBS Waivers is $195,000 combined between the two applicants/spouses, and the income limit is a combined $2,106 / month. For a married applicant with just one spouse applying for HCBS Waivers, the applicant spouse has a $130,000 asset limit and a $1,564 / month income limit for 2022, and the non-applicant spouse has a $137,400 asset limit and no income limit.

Medi-Cal applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Medi-Cal has a “look-back” period of 2.5 years. This means the state will look back into the previous 2.5 years of the applicant’s financial records to make sure they have not given away assets. California is in the process of removing the asset limit as part of Medi-Cal eligibility, but this has not happened yet, so Medi-Cal applicants should still be sure not to break the “look-back” rule.

Functional Requirements
The functional, or medical, criteria for Medi-Cal’s HCBS Waivers is needing a Nursing Facility Level of Care (NFLOC), which means the applicant requires the kind of full-time care that can only be provided in a nursing home. This is determined through a state assessment and reports from the applicant’s doctors and other relevant healthcare professionals.

 

Medi-Cal Aged Blind and Disabled (ABD) Medicaid Eligibility Criteria

Financial Requirements
California residents have to meet an an asset limit and an income limit in order to be financially eligible for Aged Blind and Disabled (ABD) / Regular Medicaid. For a single applicant in 2022, the asset limit is $130,000, which means they must have $130,000 or less in countable assets. Countable assets include bank accounts, retirement accounts, stocks, bonds, certificates of deposit, cash and any other assets that can be easily converted to cash. An applicant’s home does not always count as an asset (see the red box below for more details), and there are other non-countable assets like funeral trusts and Medicaid-approved annuities. The 2022 income limit for a single applicant is $1,564 / month. Almost all income is counted – IRA payments, pension payments, Social Security benefits, property income, alimony, wages, salary, stock dividends, etc.

For married applicants with both spouses applying, the 2022 asset limit for ABD Medicaid is $195,000 combined between the two applicants/spouses, and the income limit is a combined $2,106 / month. For a married applicant with just one spouse applying for HCBS Waivers, the asset limit is $130,000 combined and the income limit is $2,164 / month.

Medi-Cal applicants are not allowed to give away their assets in order to get under the asset limit. To make sure they don’t, Med-Cal has a “look-back” period of 2.5 years. This means the state will look back into the previous 2.5 years of the applicant’s financial records to make sure they have not given away assets. California is in the process of removing the asset limit as part of Medi-Cal eligibility, but this has not happened yet, so Medi-Cal applicants should still be sure not to break the “look-back” rule.

Functional Requirements
The functional requirements for ABD / Regular Medicaid are being blind, disabled or aged. Applicants are not required to need a Nursing Facility Level of Care like they are for Nursing Home Medicaid or HCBS Waivers. Medi-Cal will, however, perform an assessment of ABD Medicaid beneficiaries and their ability to perform Activities of Daily Living (moving, bathing, dressing, eating, toileting) to determine the kind of services the applicant needs and the state will cover.

 How Medi-Cal Counts the Home
One’s home is often their most valuable asset and if counted towards Medi-Cal’s asset limit, it would likely cause them to be over the limit for eligibility. Most states have a home equity interest limit, allowing the home to be exempt up to a maximum amount. California is unique in that there is no equity interest limit. However, for Medi-Cal Long Term Care, a few conditions must be met for the home to remain exempt and not be counted as an asset. If the Medi-Cal applicant lives in their home or has a spouse, minor child, or blind or disabled child of any age who lives there, the home is exempt. If the applicant resides in a nursing home, or lives outside the home elsewhere, and none of the abovementioned persons live in the home, they must file an “intent to return” home for it to remain exempt. This applies to all 3 types of Medicaid.

 

Applying For Medi-Cal Long Term Care Programs

The first step in applying for a Medi-Cal Long Term Care program is deciding which of the three programs discussed above you or your loved one want to apply for – Nursing Home Medicaid, Home and Community Based Service (HCBS) Waivers or Aged Blind and Disabled Medicaid.

The second step is determining if the applicant meets the financial and functional criteria, also discussed above, for that Long Term Care program. Applying for Medi-Cal when not financially eligible will result in the application, and benefits, being denied.

During the process of determining financial eligibility, it’s important to start gathering documentation that clearly details the financial situation for the Medi-Cal applicant. These documents will be needed for the official Medi-Cal application. Necessary documents include 30 months of quarterly bank statements from all accounts; the most recent monthly or quarterly statements from all investments, IRAs, 401Ks, annuities and any other financial accounts; a letter from the Social Security Administration showing the applicant’s gross Social security income and deductions; tax forms to verify income streams including wages, pensions, royalties and interest; lists of items of any trusts; proof life insurance (if the applicant has any) and a list of beneficiaries; Power of Attorney documentation.

After financial eligibility requirements are checked and double checked, documentation is gathered, and functional eligibility is clarified, there are three ways a California resident can apply for Medi-Cal and the three long-term care programs Nursing Home Medicaid, HCBS Waivers or ABD Medicaid – online, through the mail or in person. People who need help with the application process can call the Covered California Customer Service Center at 1-800-300-1506.

Once the application is received, it will usually take 45-90 days to be reviewed and approved or denied by the state. It’s also possible applications that are missing information or have mistakes will be returned.

 

Choosing a Medi-Cal Nursing Home

Once an applicant has been approved for Nursing Home Medicaid through Medi-Cal, they need to choose which Medicaid-approved nursing home they will live in. Even though Nursing Home Medicaid is an entitlement, Medi-Cal will only cover stays and care in approved nursing homes. The California Health Facilities Database (Cal Health Find) provides information on all of the nursing homes/skilled nursing facilities in the state, including whether or not they accept Medi-Cal. Nursing homes can be searched by zip code, city or county. Nursing Home Compare is a federal government website that has information about more than 15,000 nursing homes across the country. All of the nursing homes on this site are either Medicaid- or Medicare-approved.